Georgia Department of Labor
Request for Weekly Pandemic Unemployment Assistance (PUA) Payment
A. Applicant Information
First Name Middle Name Last Name Last 4 Digits of SSN
Mailing Address Street Apt./Unit Career Center
Mailing Address City State Zip Week Ending Date (WED)
B. Applicant’s Request
1. Were you able, available and actively seeking work during this week? YES NO
If NO, explain.
2. Did you refuse any work offered this week? YES NO
If YES, explain.
3. Did you work or earn wages in employment or self-employment? YES NO
If YES, enter the following:
Name of Employer: _____________________________________________________________________________
Gross Earnings Paid: $_________. ____
Are you still working for this employer? YES NO
If NO, select reason for separation: Job Ended Still Working Discharged Quit
4. Did you apply for and receive unemployment compensation under any type of State or Federal Program YES NO
during this week?
If YES, enter the following:
Payment Type: __________________________________Amount Received: $________.____ Per Unit: ________
5. Have you received or will you receive any payments for loss of wages due to illness or disability during this week? YES NO
If YES, enter the following:
Payment Type: __________________________________Amount Received: $________.____ Per Unit: ________
6. Have you received or will you receive any type of payment from a private income protection insurance plan YES NO
during this week?
If YES, enter the following:
Payment Type: __________________________________Amount Received: $________.____ Per Unit: ________
7. Have you received any payments from a supplemental unemployment benefit (SUB) plan during this week? YES NO
If YES, enter the following:
Payment Type: __________________________________Amount Received: $________.____ Per Unit: ________
8. Have you received payments from any retirement, pension, or annuity under a public or private plan or system YES NO
during this week?
If YES, enter the following:
Payment Type: __________________________________Amount Received: $________.____ Per Unit: ________
DOL-5158PUA (10/20)
Georgia Department of Labor
Request for Weekly Pandemic Unemployment Assistance (PUA) Payment
C. Applicant’s Certification
I certify I am totally or partially unemployed this week because:
I have been diagnosed with COVID-19.
A member of my household has been diagnosed with COVID-19.
I am providing care to a family member or other individual in my household who has been diagnosed with COVID-19.
I am providing care for a child or individual, for whom I have primary caregiving responsibility, who cannot attend school or
another facility because of closure due to COVID-19.
I am unable to report to my place of work because a quarantine has been imposed due to COVID-19.
I have been advised by a health care provider to self-quarantine due to COVID-19.
I was scheduled to start employment, but no longer have a job or I am unable to reach the job due to COVID-19.
I have become the breadwinner or major support for my household because the head of household died as a direct result
of COVID-19.
I had to quit my job as a direct result of COVID-19.
My place of employment is closed as a direct result of COVID-19.
I am not unemployed or partially unemployed or unable to work due to COVID-19.
Enter reason for requesting payment.
I am requesting a weekly Pandemic Unemployment Assistance (PUA) payment. By my signature, I certify the information provided is
true and correct to the best of my knowledge and belief. I understand the law prescribes penalties, possible forfeiture of assistance,
and/or criminal prosecution for misrepresentation or concealment of facts in order to obtain or increase assistance for myself or
someone else. I understand that I may be required to repay any Pandemic Unemployment Assistance I am not entitled to receive.
Signature Date
DOL-5158PUA (10/20)
